Psychiatric care in Quebec needs more compassion, says coroner investigating woman's suicide death

WARNING: This story contains discussion of suicide.If you or someone you know is struggling with thoughts of self-harm, see the end of this story for resources.

Psychiatric practices in Quebec are in need of a major overhaul, according to findings following a coroner's public inquiry into the death of Amlie Champagne, a young woman who took her life after battling both Lyme disease and the province's public health system.

In a report published on Wednesday, coroner Julie-Kim Godin issued 19 recommendationsto Quebec's Health Ministry, the Quebec College of Physicians and othergroups representing health-care professionals in the hopeofprotecting young women and other patients.

In 2022, Amlie'sdeath gained national attention after her father Alain Champagne the CEO and president of the Jean Coutu Group, a chain of Quebec pharmacies made the announcement in a LinkedIn post.

In an interview with radio host Paul Arcand on 98.5 FM at the time, he revealed that his daughter Amlie suffered from significant sleep disorders, auditory hallucinations. He said her personality had changed weeks prior to her death.

After a suicide attempt at the family's cottage in the Eastern Townships, he said his daughter was taken toHtel-Dieu Hospital in Sherbrooke.

While there, Amlie was put under observation for three days and two nights on a stretcher in the hallway. But staff reportedly told the family that she could not be treated in Sherbrooke because she did not live in the region. They said she had to be transferred to Notre-Dame Hospital in Montreal.

Her father said hospital staff told him hersituation had stabilized and she did not represent a danger to herself.

But Amliehad the right to be treated in Sherbrooke.

"In Quebec, every user has the right to consult at the location of their choice," Godin, the coroner, told CBC News in an interview on Thursday.

Amlie took her life on Sept. 11, 2022 just a few days after being discharged from Htel-Dieu.

Her three-day stay at Htel-Dieuand her death followed what her father described as years of bouncing around from one health-care professional to the next, hoping to receive proper care a reality the coroner highlighted her report.

"Her story sadly illustrates the phenomenon of revolving doors in Quebec's psychiatric emergency departments, and the undesirable effects that ensue," wrote Godin in the report.

'A ping-pong ball to the left and to the right'

Godin's report states this "period of medical wandering" fuelled Amlie'sdistress.

But based on a number of testimonies during the public inquiry, Godin concluded that Amlie'sstory is not an isolated case and has many similarities with thoseof other people with a possible or confirmed diagnosis of Lyme disease or persistent symptoms.

What's more, the report highlighted an increase in the number of people going to emergency rooms for suicidal ideation between 2022 and 2023.According to the coroner, the numbers also showeda marked increase for young girls and women in three age groupsages10 to 14, between 15 to 19 and adults between20 to 34.

Godin made several recommendations to the province's Health Ministry and groups representing health-care professionals.She said they should take new measures to ensure that doctors working with patients with mental health issues treat them with "dignity, compassion."

She also emphasized the importance of continuity and stability in an episode of care.

"Faced with an unstable user or one in a crisis situation, there are certainly many benefits to be gained from limiting transfers and the number of different doctors," Godin wrote in her report.

She also asked the Health Ministry to "expand and harmonize" admission criteria for specialized clinics so that patients with a suspected or confirmed diagnosis of Lyme disease could get help quickly.

The report also highlights thelack of follow-up between medical consultations.

"She has consulted countless doctors, undergone countless examinations, tests and diagnoses.... without there being any common thread between the follow-up and each consultation," Godin told CBC. "She walked around like a ping-pong ball to the left and to the right."

'Without delay and without discrimination'

Dr. Pierre Bleau, psychiatrist and Quebec's national director of mental health and forensic psychiatry services, says staff in health-care facilities often have the reflexto refer people to places closer to their homes rather than taking them on as patients.

"It's a red flag that she [Godin] raised and I agree with her that we need to come up with a better culture," he said.

Bleausays the province's Health Ministryagrees with every recommendation the coroner made.

"Most of the recommendations arepart of what we've been working on for the past several years," he added.

Amlie's father was not available for an interview on Thursday.

The Champagne family did issue a statement, however,expressingits gratitude for the coroner's report, adding it was particularly touched by the "importance given to humanizing care, dignity, and kindness toward patients in distress."

"It is imperative that concrete measures are taken to ensure that no patient is neglected, and that the necessary care is offered without delay and without discrimination," read the family's statement.

The Association des mdecins psychiatres (AMPQ) said it wished to "add its voice to the coroner's concerns for adequate facilities for patients who require a calming environment."

"The AMPQ intends to follow up on recommendations to improve the communication and approach with patients with mental health problems or suicidal manifestations," read the statement.

On X, the Quebec's College of Physicianssaid it wanted a better collaboration and information sharingbetween health-care professionalsto "ensure timely intervention and avoid tragedies."

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).
• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling onthe website.
• Canadian Association for Suicide Prevention:Find a 24-hour crisis centre.
• This guide from theCentre for Addiction and Mental Healthoutlines how to talk about suicide with someone you're worried about.